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GUIDELINE
Obsessive compulsive disorder
D J Stein
1. Introduction
This guideline focuses on the pharmacotherapy of obsessivecompulsive disorder (OCD). OCD is characterised by obsessions and
compulsions. A number of other disorders are also characterised by
repetitive thoughts and rituals and may also respond to modifications
of standard OCD treatment. These so-called OCD spectrum disorders
include body dysmorphic disorder (characterised by recurrent
concerns with imagined ugliness), hypochondriasis (characterised
by recurrent concerns with imagined illness), trichotillomania
(characterised by recurrent hair-pulling), and obsessive-compulsive
personality disorder.[1] The Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition[2] has a new chapter on obsessive-compulsive
and related disorders, which includes several of these conditions.
2. Diagnosis and clinical characteristics
Evidence indicates that OCD is commonly underdiagnosed and
undertreated.[3] There is also the converse possibility that various
disorders with intrusive symptoms, such as post-traumatic stress
disorder or generalised anxiety disorder, can be misdiagnosed as
OCD. Diagnostic criteria for OCD are provided in Table 1.[4]
3. Assessment
Most patients with OCD have both obsessions (which increase anxiety)
and compulsions (which aim to decrease anxiety), particularly given
that the Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition[2] definition of compulsion includes mental rituals. The most
common obsessions centre around concerns of contamination, harm,
hoarding, and sexual, somatic and religious preoccupations, while the
most common compulsions include washing, checking, repeating,
ordering, counting, and hoarding.[5] The disorder is highly comorbid
with obsessive-compulsive and related disorders, major depressive
disorder, anxiety disorders, alcohol dependence, eating disorders and
tic disorders.[6,7] Evaluation should include assessment of symptom
pattern, severity, and functional impairment. Comorbid Axis I and
II disorders, including tic disorders, as well as medical conditions
(including pregnancy) and disorders need to be accurately identified.
There is growing evidence that OCD and/or tics in some patients,
particularly children, are precipitated or exacerbated by streptococcal
or other infections.[8]
Evaluation of the OCD patient also requires attention to
psychosocial factors that may have precipitated or exacerbated
OCD symptoms. For example, are family members involved in the
patient’s rituals? What is the patient’s explanatory model of OCD does he or she regard it as a sign of weakness or as evidence of brain
dysfunction?
4. Treatment
4.1 Treatment goals
The goals of treatment of OCD are to reduce symptom frequency and
severity and to improve functioning and quality of life. Treatment
goals also encompass minimising medication adverse effects, helping
the patient develop coping strategies for their OCD and related
stressors, and educating the patient and family regarding the disorder
and its treatment.[7]
4.2 General aspects of treatment
In this discussion, we assume that the patient is an adult. Nevertheless,
there are increasing data on the pharmacotherapy of OCD in children. [9,10]
Indeed, the algorithm (see Fig. 1 below) can readily be adapted for
children, bearing in mind considerations such as differences in dosing
and differences in risk-benefit determination (e.g. clinicians are less
likely to use untested augmentation strategies in children). Consultation
with a child psychiatrist may well be indicated in such cases.
Table 1. Criteria for obsessive-compulsive disorder*
A. Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
1. Recurrent and persistent thoughts, impulses, or images that are
experienced, at some time during the disturbance, as intrusive
and inappropriate and that cause marked anxiety or distress
2. †The thoughts, impulses, or images are not simply excessive
worries about real-life problems
3. The person attempts to ignore or suppress such thoughts,
impulses, or images, or to neutralise them with some other
thought or action
4. † The person recognises that the obsessional thoughts, impulses,
or images are a product of his or her own mind (not imposed
from without as in thought insertion)
Compulsions as defined by (1) and (2):
1. Repetitive behaviours (e.g. hand washing, ordering, checking)
or mental acts (e.g. praying, counting, repeating words silently)
that the person feels driven to perform in response to an
obsession, or according to rules that must be applied rigidly
2. The behaviours or mental acts are aimed at preventing
or reducing distress or preventing some dreaded event or
situation; however, these behaviours or mental acts either are
not connected in a realistic way with what they are designed to
neutralise or prevent or are clearly excessive
B. At some point during the course of the disorder, the person has
recognised that the obsessions or compulsions are excessive or
unreasonable
C. The obsessions or compulsions cause marked distress, are time
consuming (take more than 1 hour a day), or significantly interfere
with the person’s normal routine, occupational (or academic)
functioning, or usual social activities or relationships
D. ‡If another Axis I disorder is present, the content of the obsessions or
compulsions is not restricted to it
E. The disturbance is not due to the direct physiological effects of a
substance (e.g. a drug of abuse, a medication) or a general medical
condition.
* Adapted from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision; DSM-IV-TR.[4] For educational purposes only..
†
Omitted from the DSM-V[2]
‡
This has been changed in the DSM-V[2] ‘The disturbance is not better explained by the symptoms
of another mental disorder.’
August 2013 Vol. 19 No. 3 - SAJP 180
GUIDELINE
The initial treatment of OCD can arguably be either medication or
psychotherapy as both approaches are efficacious. Several factors
may complicate OCD, thus impacting on decisions about the choice
of pharmacotherapy and other interventions. The most important
factors, along with their treatment implications, are listed below.
In addition, prior response to treatment and patient preference are
important considerations.
4.2.1 Severity
Patients with severe symptoms may require brief hospitalisation
to help contain symptoms. In general, however, the principles of
behaviour therapy suggest that patients should attempt to continue
with their ordinary daily routines where possible.
4.2.2 Melancholia
There is some evidence that tricyclic antidepressants (TCAs) may be more
effective than selective serotionin reuptake inhibitors (SSRIs) in patients
with depression accompanied by melancholic features[11] and in possibly
related subgroups such as in-patients with depression,[11-13] although not
all evidence is consistent.[14] Melancholic features of depression include
loss of pleasure in activities, lack of reactivity to pleasurable stimuli, and
various neurovegetative symptoms such as exacerbation of depression in
the morning, early-morning awakening, and significant weight loss. The
only TCA that is effective in OCD is clomipramine.
4.2.3 Tourette’s disorder
This disorder is characterised by both motor and vocal tics. Many
patients with Tourette’s disorder have comorbid OCD. Although
this OCD may respond to standard OCD treatments, additional
medication that targets the tics (e.g. dopamine blockers such as
haloperidol, pimozide, or risperidone) may be necessary for resolution
of the range of symptoms that characterise the disorder.[15]
4.2.4 Pregnancy, lactation, menopause
Pharmacotherapy should ideally be avoided during pregnancy and
lactation. Nevertheless, where clinical considerations outweigh the
risk of medication, such intervention should be considered after
consultation with a specialist. In particular, there is growing literature
pointing toward the relative safety of fluoxetine in pregnancy.[16]
4.2.5 Comorbid medical disorders and medications
Clinicians need to be aware of the multiple interactions between
medications used in the treatment of OCD and other medications,
as well as the impact of a medication’s adverse effects on medical
disorders. Fortunately, certain SSRIs have relatively few interactions
with other medications, and the SSRIs as a class are well tolerated in
most medical disorders.
4.3 Pharmacological treatment
Refer to 4.5 and 4.6 below.
4.4 Non-pharmacological treatment
Psycho-education as part of the management of OCD is crucial.
Similarly, cognitive-behavioural therapy (CBT) is an important
aspect of OCD treatment, whether used alone or in combination with
medication.[17] CBT for OCD has been delivered in individual, group,
181 SAJP - August 2013 Vol. 19 No. 3
and family therapy formats. The number and length of treatment
sessions vary across different studies, but some guidelines recommend
13 - 20 weekly sessions for most patients.[7]
4.5 Acute treatment
Patient motivation and ability to comply with pharmacotherapy and/
or psychotherapy are important considerations in choosing a first-line
treatment approach. CBT and serotonin reuptake inhibitors (SRIs) are
both considered safe and effective first-line treatments for OCD.[5,7]
The decision of whether to commence CBT or an SRI will depend on
a number of factors including the nature and severity of symptoms,
presence of co-occurring psychiatric and medical comorbidity and
their treatments, patients’ access to CBT, past treatment history, and
patient preference.[5,7] CBT alone, consisting of exposure and response
prevention, is recommended as initial treatment for a patient who is not
too depressed, anxious, or severely ill to co-operate with this treatment
modality, or who prefers not to take medications and is willing to engage
with CBT. Initiating treatment with an SRI is recommended for a patient
who has previously responded well to an SRI or other drug, prefers
medication treatment or is not suited for CBT.[7]
The first line of medication in the treatment of OCD should
comprise an SRI. Consistent with growing evidence for the importance
of serotonin in OCD, both clomipramine and the SSRIs appear
to be more effective than the noradrenergic reuptake inhibitor,
desipramine, in the treatment of OCD.[18,19] The efficacy and safety
of clomipramine and the SSRIs in the treatment of OCD have been
well researched, with studies indicating that at least half of patients
will respond to one of these agents. The SRIs are also useful for
body dysmorphic disorder, hypochondriasis, obsessive-compulsive
symptoms in Tourette’s disorder, and possibly (albeit with relatively
less robust responses) in hair-pulling disorder (trichotillomania),
excoriation (skin-picking) disorder, so-called compulsive sexual
behaviour, and pathological gambling.[20,21] Note, however, that other
agents may be preferable as first-line options in some of these
conditions, e.g. given recent data that N-acetyl-cysteine is useful in
hair-pulling disorder, this is an important consideration.
An immediate question, however, is which SRI to use first. Given
the apparent lack of differences in efficacy between the SRIs, the sideeffect profile of these agents may be an important issue in considering
which agent to use first. Certainly, there are invariably fewer sideeffects during treatment with the SSRIs than during treatment
with clomipramine. Therefore, it seems reasonable to suggest that
treatment of OCD be initiated with an SSRI.
While all SSRIs appear to have similar efficacy, individual patients
may respond well to one medication and not to another. In choosing
among the SSRIs, it is important to consider the safety and acceptability
of particular side-effects for the patient, potential drug interactions,
past treatment response, and the presence of co-occurring general
medical conditions.[7] Low doses should initially be used in patients
with comorbid panic disorder.
Most patients will not experience substantial improvement until
4 - 6 weeks after initiating medication, and some patients who will
ultimately respond will experience little improvement by 8 - 10
weeks. [5,7] To determine response to medication, it is important to ask
about change in those symptoms initially targeted for treatment. Sideeffects of the medication should also be determined, with particular
GUIDELINE
attention to those that patients may be reluctant to disclose (e.g.
sexual dysfunction). It may be useful to complete a symptom rating
scale (Table 2)[22] to help quantify response to medication.
Patients who are intolerant of a particular medication can of course
be switched to another agent. Within the SRIs, adverse effects may not
be seen when an alternative SSRI or clomipramine is used.
When there is a poor response to medication, it is important to
optimise dosage and duration of the medication. Although some
patients with OCD respond to standard doses of SRIs, others require
doses that are much higher than in depression. In adults, clomipramine
should be increased to approximately 250 mg, and the SSRIs should
be increased to maximal dosages (e.g. 60 - 80 mg of fluoxetine)
bearing in mind recent black box warnings (e.g. citalopram should
not be increased higher than 40 mg). Unfortunately, the likelihood of
side-effects also increases at these doses. Electrocardiogram (ECG)
monitoring may be necessary when children and adolescents, or
patients with pre-existing heart disease, are treated with clomipramine.
Response to SSRIs in OCD may take rather longer than in many
other disorders - up to 12 weeks. It is obviously important to give
each patient a trial of medication that is of adequate duration. Patients
therefore need to be educated that response may take a significant
length of time and that they need to remain optimistic even when no
change is seen at first.
At the end of a clinical trial of optimal dose and duration, patients
should be thoroughly reassessed. There is growing recognition of
the importance of residual anxiety symptoms in causing disability
and predicting relapse, and of the consequent necessity of aiming for
remission of symptoms as the endpoint of treatment.[23] Nevertheless,
many OCD patients who are judged ‘responders’ to medication
therapy may continue to experience obsessions and compulsions,
albeit with less intensity. In clinical trials, a decrease of 25 - 35% on the
Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) may correspond
to a categorical treatment response.[22]
4.6 Maintenance treatment
In patients where an SRI is effective, maintenance pharmacotherapy
should be instituted. Rapid discontinuation of these agents risks the
return of symptoms. Nevertheless, a maintenance dose of SSRIs in OCD
may be lower than the dose initially required during acute treatment. [21]
At least a year of maintenance pharmacotherapy is reasonable. When
a decision is made to attempt discontinuation of medication, it is
advisable to taper medication off slowly (e.g. by 25% every 2 months).
Concomitant behavioural treatment (exposure therapy and response
prevention) during pharmacotherapy may well increase chances of
being able to discontinue medication without relapse.
4.7 Managing partial and non-responders
Comparison of augmentation with switching strategies in OCD has not
been well researched. Augmentation offers the advantage of retaining
any possible gains from the first agent, but the potential disadvantages
of polypharmacy (more side-effects, drug interactions). [24] Of all the
augmentation strategies in the treatment of OCD, perhaps the most
important is augmentation of pharmacotherapy with additional
psychotherapy.[25]
Combined SRI and CBT treatment can be considered when the
patient has a co-occurring disorder that is SRI-responsive or has a
partial response to monotherapy. Combination of an SRI and CBT may
also reduce the chance of relapse when medication is discontinued. In
patients who have had a partial response to CBT monotherapy, it may
be useful to increase the intensity of treatments.[7]
However, when there is a partial response despite an optimum trial of
medication, or when there are comorbid tics, it may be useful to consider
augmentation. Certainly, in patients with comorbid tics, there is good
evidence that augmentation of an SRI with a dopamine blocker can be
effective.[26] About one-third to one-half of treatment-refractory OCD
patients will have a meaningful treatment response to antipsychotic
augmentation. The introduction of the new-generation antipsychotics
has led to increased use of these agents in the augmentation therapy
of OCD, and they appear useful in treatment-refractory patients even
in the absence of comorbid tics. [27-29] Another possible strategy is to
supplement an SSRI with a low dose of clomipramine,[30] although careful
monitoring of adverse effects and ECGs may be warranted with such a
combination. Other augmentation strategies have been suggested, but
there are few positive controlled trials. There is also relatively little work
on augmentation strategies in OCD-related disorders, although addition
of a dopamine blocker may also be useful in some of these patients.[31]
When OCD does not respond to a clinical trial of optimal dose and
duration, it is useful to reassess a number of factors. The presence
of certain features may impact on the choice of the subsequent
intervention.
4.7.1 Compliance
Clinicians often overestimate the compliance of their patients and
it is often useful to check with patients and their families whether
medication is being taken as prescribed. Many patients worry that
medication is addictive or is a ‘crutch’.
4.7.2 Comorbid substance use
In patients who fail to respond to pharmacotherapy, the possibility of
comorbid substance use should again be considered. There may be a
need for withdrawal before tackling the OCD per se.[32,33]
4.7.3 Comorbid personality disorders
Although SSRIs may be useful, additional interventions such as
psychotherapy may be crucial in patients with OCD and comorbid
personality disorder. While improvement in OCD symptoms may
reduce maladaptive behaviour in comorbid personality disorder, the
personality disorder itself may need to be a major target of treatment.
4.7.4 Underlying medical disorder
Patients with obsessive-compulsive and related disorders who
fail to respond to medication should be thoroughly reassessed for
an underlying medical disorder. In OCD in children, the role of
streptococcal throat infection may be particularly important.
4.7.5 Pharmacokinetic issues
Drug-drug interactions may result in a subtherapeutic dose of the
prescribed antidepressant.
4.7.6 Psychosocial issues
Psychosocial circumstances that continue to complicate the course
of OCD need to be assessed, as these may necessitate appropriate
August 2013 Vol. 19 No. 3 - SAJP 182
GUIDELINE
Table 2. Yale-Brown Obsessive-Compulsive Scale[22]
Question
Answer scale
‘I am now going to ask several questions about your obsessive thoughts.’
(Make specific reference to the patient’s target obsessions)
1. T
ime occupied by obsessive thoughts
0 = None.
Q: How much of your time is occupied by obsessive thoughts?
How frequently do the obsessive thoughts occur?
1 = Mild, less than 1 hour/day or occasional intrusion.
2 = Moderate, 1 to 3 hours/day or frequent intrusion.
3 = Severe, greater than 3 and up to 8 hours/day or very frequent intrusion.
4 = Extreme, greater than 8 hours/day or near constant intrusion.
2. Interference due to obsessive thoughts
0 = None.
Q: How much do your obsessive thoughts interfere with your social
or work (or role) functioning? Is there anything that you don’t do
because of them?
1 = Mild, slight interference with social or occupational activities, but
overall performance not impaired.
2 = Moderate, definite interference with social or occupational
performance, but still manageable.
3 = Severe, causes substantial impairment in social or occupational
performance.
4 = Extreme, incapacitating.
3. Distress associated with obsessive thoughts
0 = None.
Q: How much distress do your obsessive thoughts cause you?
1 = Mild, not too disturbing.
2 = Moderate, disturbing, but still manageable.
3 = Severe, very disturbing.
4 = Extreme, near constant and disabling distress.
4. Resistance against obsessions
Q: How much of an effort do you make to resist the obsessive thoughts?
How often do you try to disregard or turn your attention away from
these thoughts as they enter your mind?
0 = Makes an effort to always resist, or symptoms so minimal doesn’t need
to actively resist.
1 = Tries to resist most of the time.
2 = Makes some effort to resist.
3 = Yields to all obsessions without attempting to control them, but does so
with some reluctance.
4 = Completely and willingly yields to all obsessions.
5. Degree of control over obsessive thoughts
0 = Complete control.
Q: How much control do you have over your obsessive thoughts? How
successful are you in stopping or diverting your obsessive thinking?
Can you dismiss them?
1 = Much control, usually able to stop or divert obsessions with some effort
and concentration.
2 = Moderate control, sometimes able to stop or divert obsessions.
3 = Little control, rarely successful in stopping or dismissing obsessions,
can only divert attention with difficulty.
4 = No control, experienced as completely involuntary, rarely able to even
momentarily alter obsessive thinking.
The next several questions are about your compulsive behaviours.’ (Make
specific reference to the patient’s target compulsions)
6. Time spent performing compulsive behaviours
0 = None.
Q: How much time do you spend performing compulsive behaviours?
How much longer than most people does it take to complete routine
activities because of your rituals? How frequently do you perform
compulsions?
1 = Mild (spends less than 1 hour/day performing compulsions), or
occasional performance of compulsive behaviours.
2 = Moderate (spends from 1 to 3 hours/day performing compulsions), or
frequent performance of compulsive behaviours.
3 = Severe (spends more than 3 and up to 8 hours/day performing
compulsions), or very frequent performance of compulsive behaviours.
4 = Extreme (spends more than 8 hours/day performing compulsions), or
near constant performance of compulsive behaviours (too numerous to
count).
continued...
183 SAJP - August 2013 Vol. 19 No. 3
GUIDELINE
Table 2 (continued). Yale-Brown Obsessive-Compulsive Scale[22]
Question
Answer scale
7. Interference due to compulsive behaviours
0 = None.
Q: How much do your compulsive behaviours interfere with your social
or work (or role) functioning? Is there anything that you don’t do
because of the compulsions?
1 = Mild, slight interference with social or occupational activities, but
overall performance not impaired.
2 = Moderate, definite interference with social or occupational
performance, but still manageable.
3 = Severe, causes substantial impairment in social or occupational
performance.
4 = Extreme, incapacitating.
8. Distress associated with compulsive behaviour
0 = None.
Q: How would you feel if prevented from performing your
compulsion(s)? How anxious would you become? How anxious do
you get while performing compulsions until you are satisfied they are
completed?
1 = Mild, only slightly anxious if compulsions prevented, or only slight
anxiety during performance of compulsions.
2 = Moderate, reports that anxiety would mount but remain manageable if
compulsions prevented, or that anxiety increases but remains manageable
during performance of compulsions.
3 = Severe, prominent and very disturbing increase in anxiety if
compulsions interrupted, or prominent and very disturbing increase in
anxiety during performance of compulsions.
4 = Extreme, incapacitating anxiety from any intervention aimed at
modifying activity, or incapacitating anxiety develops during performance
of compulsions.
9. Resistance against compulsions
Q: How much of an effort do you make to resist the compulsions?
0 = Makes an effort to always resist, or symptoms so minimal doesn’t need
to actively resist.
1 = Tries to resist most of the time.
2 = Makes some effort to resist.
3 = Yields to almost all compulsions without attempting to control them,
but does so with some reluctance.
4 = Completely and willingly yields to all compulsions.
10. Degree of control over compulsive behaviour
0 = Complete control.
Q: H
ow strong is the drive to perform the compulsive behaviour? How
much control do you have over the compulsions?
1 = Much control, experiences pressure to perform the behaviour but
usually able to exercise voluntary control over it.
2 = Moderate control, strong pressure to perform behaviour, can control it
only with difficulty.
3 = Little control, very strong drive to perform behaviour, must be carried
to completion, can only delay with difficulty.
4 = No control, drive to perform behaviour experienced as completely
involuntary and overpowering, rarely able to even momentarily delay
activity.
intervention. In particular, the participation of friends and family in
rituals may serve to derail treatment.
After the failure of an adequate clinical trial of medication in a
patient where reassessment sheds no light on any further unresolved
factors, a different agent should be used. Although an SRI has
less chance of being effective in patients who have already failed a
number of trials of other SRIs, some of these patients (approximately
one-third of non-responders to initial SRI monotherapy) will in fact
ultimately respond to a new SRI.[34] Given the possible superiority
of clomipramine in certain cases of OCD and depression, it may be
argued that all OCD patients who have failed to respond to one or
more of the SSRIs deserve a trial of clomipramine.[35] While results
of studies correlating plasma drug levels and therapeutic response in
OCD have been mixed, in the case of clomipramine obtaining drug
levels at high doses may be useful. Anecdotal experience suggests
that certain non-SRI agents, such as the classic monoamine oxidase
inhibitors and venlafaxine, may on occasion be effective in treatmentresistant OCD.[36] Recent trials of intravenous clomipramine also
show efficacy in treatment-resistant OCD.[37]
For patients who have failed multiple medication and behavioural
treatments (including intensive partial or full hospitalisation
programmes),[38] and where severity of the disorder is marked,
neurosurgery should also be considered.[39] Several studies have
suggested that specific lesions to or deep-brain stimulation of
components of corticostriatal and related pathways may lead to
significant reduction in OCD symptoms in treatment-refractory
August 2013 Vol. 19 No. 3 - SAJP 184
GUIDELINE
patients. Patients can be referred to specialised
centres for such treatments.
Diagnosis of obsessive-compulsive disorder
5. Algorithm
Fig. 1 outlines the treatment.
Complicated?
6. Summary points
• CBT and the serotonin reuptake inhibitors
(SRIs), clomipramine and the SSRIs, are
efficacious and safe first-line treatments
for OCD.
• Whether to commence CBT or an SRI
will depend on the nature and severity
of symptoms, presence of co-occurring
psychiatric and medical comorbidities
and their treatments, a patient’s access to
CBT, past treatment history, and patient
preference.
• CBT alone, consisting of exposure and
response prevention, is recommended
as first-line for a patient who is not
too depressed, anxious, or severely ill to
co-operate with this treatment modality, or
who prefers not to take medications and is
willing to engage with CBT.
• SRI first-line treatment is recommended for
a patient who has previously responded well
to an SSRI or other drug, prefers medication
treatment, or is not suited for CBT.
• Most patients will not experience substantial
improvement until 4 - 6 weeks after
initiating medication, and some patients
who ultimately respond will experience little
improvement by 8 - 10 weeks.
• Although some patients with OCD respond
to standard doses of SRIs, others require
doses that are much higher than those used
for depression. In adults, clomipramine
should be increased to approximately 250
mg, and the SSRIs should be increased to
maximal safe dosages (e.g. 60 - 80 mg of
fluoxetine).
• At least a year of maintenance
pharmacotherapy is reasonable in patients
who respond to medication.
• CBT (exposure and response prevention)
can be used alone or in combination
with medication. Psycho-education is also
crucial.
• When there is a partial response to an
optimal trial of medication, or when
there are comorbid tics, it may be useful
to consider augmentation. Many OCD
patients will have a meaningful treatment
response to antipsychotic augmentation.
185 SAJP - August 2013 Vol. 19 No. 3
Yes
No
Serotonin reuptake inhibitor
Appropriate
intervention (see
text)
Response?
Remission?
No
No response
Intolerable
response
Optimise dose
and duration, then
reassess response
Reassess
Switch
medication, then
reassess
response
Response
Switch
medications or
augument
Optimise dose
Fig. 1. Algorithm for pharmacotherapy of obsessive-compulsive disorder.[40]
Additional reading
• J efferson JW, Altemus M, Griest JH, et al. An algorithm for the
pharmacologic treatment of obsessive compulsive disorder.
Psychopharmacology Bulletin 1996;31:487-490.
• M
arch JS, Frances A, Carpenter D, Kahn D. Treatment of
obsessive-compulsive Disorder. J Clin Psychiatry 1997;S4:172.
• S tein DJ, Emsley RA. Treatment of the difficult obsessivecompulsive disorder patient. In: Lader M, Naber D, eds.
Difficult Clinical Problems in Psychiatry. London: Martin
Dunitz, 1999.
• Stein DJ, Hollander E. Serotonin reuptake inhibitors in
obsessive-compulsive disorder and related disorders. In:
Feighner J, Boyer WF, eds. Selective Serotonin Reuptake
Inhibitors: Advances in Basic Research and Clinical Practice.
2nd ed. New York: John Wiley, 1996.
References
1. Stein DJ, Hollander E. Serotonin reuptake inhibitors in
obsessive-compulsive disorder and related disorders. In:
Feighner J, Boyer WF, eds. Selective Serotonin Reuptake
Inhibitors: Advances in Basic Research and Clinical Practice,
2nd ed. New York: John Wiley, 1996.
2. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition. Washington, DC:
American Psychiatric Association, 2013.
3. Stein DJ, Hollander E, Rowland, et al. Quality of life and
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4. American Psychiatric Association. Diagnostic and Statistical
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5. Bandelow B, Zohar J, Hollander E, et al. WFSBP Task Force
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6. Pigott TA, L’Heureux F, Dubbert B, et al. Obsessive
compulsive disorder: Comorbid conditions. J Clin Psychiatry
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7. Koran LM, Hanna GL, Hollander E, et al. Practice guideline
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8. Swedo SE, Leonard HL, Garvey M, et al. Pediatric
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9. Geller DA, Biederman J, Stewart SE, et al. Which SSRI?
A meta-analysis of pharmacotherapy trials in pediatric
obsessive-compulsive disorder. Am J Psychiatry
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10. King RA, Leonard H, March J, Work Group on Quality Issues.
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J Am Acad Child Adolesc Psychiatry 1998;37(S10):27-45.
GUIDELINE
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